Endoscopic submucosal dissection in management of colorectal tumors near or involving a diverticulum: a retrospective case series

Endoscopic submucosal dissection with the combination of a scissor-type knife and novel traction method for colonic neoplasm involving a diverticulum

Video 1A 35-mm laterally spreading tumor partially infiltrated the interior portion of the diverticular orifice in the ascending colon. Glycerol and hyaluronate solution were injected into the submucosa to maintain adequate mucosal elevation. Mucosal incision and submucosal dissection were performed using a DualKnife and insulation-tipped knife from the anal side; however, safe submucosal dissection was challenging with these knives because of severe fibrosis and abundant blood vessels in the diverticulum. Therefore, to improve the visibility of the submucosa, a scissor-type knife and a multiloop traction device was used to facilitate the submucosal dissection. Finally, en bloc resection was achieved in 117 minutes without adverse events. A part of the diverticular defect after endoscopic submucosal dissection was clipped to prevent delayed perforation.

Feasibility and safety of endoscopic submucosal dissection for lesions in proximity to a colonic diverticulum

Background/Aims

Endoscopic submucosal dissection (ESD) for diverticulum-associated colorectal lesions is generally contraindicated because of the high risk of perforation. Several studies on patients with such lesions treated with ESD have been reported recently. However, the feasibility and safety of ESD for lesions in proximity to a colonic diverticulum (D-ESD) have not been fully clarified. The aim of this study was to evaluate the feasibility and safety of D-ESD.

Methods

D-ESD was defined as ESD for lesions within approximately 3 mm of a diverticulum. Twenty-six consecutive patients who underwent D-ESD were included. Two strategic approaches were used depending on whether submucosal dissection of the diverticulum-related part was required (strategy B) or not (strategy A). Treatment outcomes and adverse events associated with each strategy were analyzed.

Results

The en bloc resection rate was 96.2%. The rates of R0 and curative resection in strategies A and B were 80.8%, 73.1%, 84.6%, and 70.6%, respectively. Two cases of intraoperative perforation and one case of delayed perforation occurred. The delayed perforation case required emergency surgery, but the other cases were managed conservatively.

Conclusions

D-ESD may be a feasible treatment option. However, it should be performed in a high-volume center by expert hands because it requires highly skilled endoscopic techniques.

Underwater Endoscopic Mucosal Resection without Submucosal Injection Facilitates En bloc Resection of Colon Adenomas Extending into a Diverticulum

Superficial colonic neoplasms sometimes extend into a diverticulum. Conventional endoscopic mucosal resection of these lesions is considered challenging because colonic diverticula do not have a muscularis propria and are deeply inverted. Even if the solution is carefully injected below the mucosa at the bottom of the diverticulum, the mucosa is rarely elevated from the diverticular orifice, and it is usually just narrowed. Although endoscopic submucosal dissection or full-thickness resection with an over-the-scope clip device enables the complete resection of these lesions, it is still challenging, time consuming and expensive. Underwater endoscopic mucosal resection without submucosal injection (UEMR) is an innovative technique enabling en bloc resection of superficial colon lesions. We report three patients with colon adenomas extending into a diverticulum treated with successful UEMR. UEMR enabled rapid and safe en bloc resection of colon lesions extending into a diverticulum.

Endoscopic Management of a Tubulovillous Adenoma Within a Diverticulum: Report of a Case and Review of Literature

Adenomas or adenocarcinomas located within a colonic diverticulum are considered a rare phenomenon that has been described in the literature. These lesions are technically difficult to manage endoscopically and usually require surgical intervention for removal. There is also an increased risk of perforation upon endoscopic resection owing to the lack of a muscular layer within the diverticulum. We report a case and include a literature review to evaluate different endoscopic techniques and propose the most effective for management of adenomas within a diverticulum. This technique is potentially comprised of employing a combined approach using a suction banding device, an over-the-scope clip (OTSC; Ovesco Endoscopy AG, Tübingen, Germany) , and hyperthemic snare to successfully remove the polyp, ensure tissue retrieval, and reduce risk of iatrogenic colonic perforation.